In Iraq, giving birth is complicated by war

In this poor village, where sheep, goats, and wild turkeys strut through the muddy streets, everybody knows Khanim's house. Her dark stone hut is where they run when their wives and mothers are ready to give birth.

In medical parlance, Khanim is a "traditional birth assistant" - trained to help women give birth, but not qualified to be a midwife. In Kurdish, she is a "mamman" and she often holds the well-being of these village women in her hard, stubby hands.

"There are doctors, there are midwives, but we don't visit anybody but Khanim," says Kafi Karim, a weatherbeaten mother of four. "We only trust God - and her."

Like her newly democratic homeland, Khanim has dealt with major birth pains the last few years. After the 2003 war that toppled Saddam Hussein, the number of women who gave birth at home shot up to about two-thirds. Of those, 80 percent had nobody with any formal training present at the birth. Far from lifesaving emergency care, many mothers died from preventable complications.

Today, nobody knows exactly how many mothers are dying in Iraq. Violence has prevented medical experts from measuring the maternal mortality rate since late 2003, when the number of Iraqi women who died from childbirth climbed to 370 per 100,000 - triple its 1990 rates and 31 times the US rate of 12. The UN Population Fund concluded that the war and its aftermath had made an old problem "suddenly become very much worse."

Medical experts worry that even more mothers are dying, their deaths uncounted and unreported due to the violence that grips this country. So people like Khanim have become a vital force in helping usher in Iraq's next generation.

In Kurdistan, the peaceful northern region where Khanim lives, poverty and ignorance keep many mothers from hospitals. But in most of Iraq, violence keeps women at home. In Baghdad, according to a 2003 Health Ministry assessment, 1 in 5 women said "insecurity" prevented them from getting healthcare during their last pregnancy.

"In Iraq, the skills are available to handle essential obstetric care, and yet it's not being done," says Lynn Amowitz, who conducted a July 2003 study of maternal healthcare in several southern Iraqi cities. "So you have to look at what the other issues are. And it's going to be much harder for a woman who's near the point of death, who is living in an insecure area, to get to a clinic - or even for a doctor to get to a clinic."

After the war, UN experts laid out recommendations for saving mothers' lives, including mobile emergency units for mothers in distress and transportation systems to get mothers to hospitals quickly. Violence has thwarted most of these plans, save for a program training nurses, doctors, and midwives.

Until Iraq stabilizes, there's another way to save mothers' lives. But it requires acknowledging home delivery, at the risk of encouraging it. This means using birth assistants like Khanim. But without proper training and close regulation, birth assistants can unwittingly endanger their patients. If a mother has potential complications or if it's a woman's first child, birth assistants and midwives are supposed to send her to a hospital. Often, they don't.

Shler Faiq Ghreeb, a doctor, sees the results firsthand: Once or twice a month, women arrive in Sulaymaniyah's maternity hospital sick or dying because they gave birth at home when they shouldn't have. Iraq's health ministry plans to stop training birth assistants. (The ministry failed to respond to several requests for comment on this article.)

Despite the dangers, most medical experts say midwives and birth assistants are necessary, because they know that Iraqi women will keep giving birth at home. And a properly trained birth assistant can save a mother's life.

Despite the villagers' faith in Khanim, she is not infallible. Last June, doctors temporarily revoked her license for attending a young mother's first birth. After a stern lecture, she promised never to do it again, and got her license back in time to attend the delivery of Ms. Karim's child.

At 40, she's a little old for childbearing, as Khanim bluntly put it. But the delivery went off without a hitch. At noon, Karim's contractions started, but she waited until they were about five minutes apart, as Khanim taught her, to send for the mamman, who helped her deliver a baby boy named Mohammed.